What is the best medication for treating excessive burps (eructation)?

Treatment of Excessive Burping (Eructation)

The best medication for excessive burping depends on the underlying type: for gastric belching related to GERD, start with PPI therapy; for supragastric belching (the most common type), baclofen may help but behavioral therapy is more effective than any medication. 1

First: Determine the Type of Belching

The critical first step is distinguishing between two fundamentally different mechanisms 1:

• Supragastric belching (voluntary): Air is sucked into the esophagus from the pharynx and immediately expelled orally without reaching the stomach. This is the most common cause of excessive belching complaints. 2
• Gastric belching (involuntary): Air is transported from the stomach through the esophagus due to transient relaxation of the lower esophageal sphincter. This occurs less frequently but with greater force than supragastric belching. 1

Diagnostic testing: Ambulatory impedance monitoring with or without high-resolution manometry (for at least 90 minutes; 24-hour impedance preferred) can differentiate these two types. 1

Medication Options Based on Type

For Gastric Belching (Involuntary)

If related to GERD: Start PPI therapy and lifestyle modifications for reflux. 1 PPIs are the most effective antisecretory drugs for GERD-related symptoms. 1

If related to excess transient lower esophageal sphincter relaxations (TLESRs): Consider baclofen, a GABA-B agonist that inhibits TLESRs. 1 Baclofen may be effective for belch-predominant symptoms and mild regurgitation, though it is often limited by central nervous system and GI side effects including dizziness, somnolence, and gastrointestinal discomfort. 1, 3

Important caveat: Start baclofen at a low dose and gradually increase to minimize side effects. Avoid abrupt discontinuation due to potential withdrawal symptoms. 3

For Supragastric Belching (Voluntary)

Medications are generally ineffective because this is a behavioral disorder where air never reaches the stomach. 1

• PPIs are typically ineffective as the reflux episodes are usually non-acidic. 4
• The primary treatment is psychoeducation (communicating findings to the patient) and brain-gut behavioral therapy. 1
• Behavioral interventions include cognitive behavioral therapy (CBT), diaphragmatic breathing, and speech therapy. 1, 5, 6

For Aerophagia (Excessive Air Swallowing)

If manometry shows influx of air into the esophagus with swallowing causing intestinal gas accumulation on abdominal X-rays, this suggests aerophagia rather than simple belching. 1, 3

• Baclofen may be considered for aerophagia. 3
• However, behavioral approaches targeting air swallowing behavior through awareness and behavioral techniques are essential. 4, 7
• Aerophagia should not be treated surgically; these patients do not have ileus and should not undergo explorative laparotomy. 7

Treatment Algorithm

1. Assess quality of life impact: If excessive belching is reducing quality of life, proceed with evaluation. 1

2. Rule out associated conditions:

   • Check for GERD symptoms (heartburn, regurgitation). If present, start PPI therapy. 1
   • Rule out rumination disorder with high-resolution manometry with impedance. 1
   • In subset of patients with nausea and vomiting, rule out gastroparesis. 1

3. Differentiate belching type with ambulatory impedance monitoring ± high-resolution manometry. 1

4. Treat based on type:

   • Gastric belching + GERD: PPI therapy 1
   • Gastric belching + excess TLESRs: Baclofen 1
   • Supragastric belching: Psychoeducation and behavioral therapy 1
   • Aerophagia: Behavioral therapy ± baclofen 3

Common Pitfalls to Avoid

• Don't prescribe PPIs empirically for all excessive belching: PPIs only work for gastric belching related to GERD, not for supragastric belching (the most common type). 1, 4
• Don't use metoclopramide: It is not recommended as monotherapy or adjunctive therapy for belching disorders. 1
• Don't overlook the behavioral component: Even when medications are appropriate, combining them with behavioral interventions improves outcomes. 1
• Don't confuse excessive belching with aerophagia: These are distinct disorders requiring different approaches. Aerophagia presents primarily with bloating and abdominal distension, not isolated belching. 2